Collection of Personal Data 9/2018 .doc

Radiation Board COLLECTION OF PERSONAL DATA

INTRODUCTION

1. This document briefly describes your rights and the means to request access to andcorrection of your personal data held by the Radiation Board.

PURPOSE

2. The Radiation Board uses the personal data provided by the clients for the processing oflicences and permits prescribed by the Radiation Ordinance, Cap 303 (the Ordinance) and otherrelated activities. The provision of personal data is obligatory under the Ordinance. The personaldata provided will be used by us for the below listed purposes. If the necessary information arelacking, we may not be able to provide the required services.

(a) Proof of eligibility;(b) Processing of applications/permits;(c) Assessment of fitness for employment in radiation work;(d) Compilation of statistics and processing complaints or enquiries;(e) Preparation of general demand note;(f) Collection of licence fees or service charges; and(g) Enforcement of the regulatory requirements of the Ordinance

HANDLING OF PERSONAL DATA

3. The personal data you provide are mainly used by us for the above purposes but they mayalso be disclosed to other Government bureaux/departments or relevant parties for the purposesmentioned in paragraph 2 above, if required. Besides, the data may only be disclosed to partieswhere you have given consent to such disclosure or where such disclosure is allowed under thePersonal Data (Privacy) Ordinance.

DISCLOSURE OF INFORMATION TO THE PUBLIC

4. The information of the licences/permits will also be posted on the Electronic RadiationLicensing and Services website (http://www.erls.gov.hk).

ACCESS TO PERSONAL DATA

5. In accordance with Sections 18 and 22 and Principle 6 of Schedule 1 of the Personal Data(Privacy) Ordinance, (Chapter 486 of the Laws of Hong Kong), you have the right to request access toand correction of the personal data supplied in your application.

ENQUIRIES

6. Enquiries concerning the personal data provided, including the access and corrections,should be addressed to:

Executive Officer (RHD) / Senior Clerical Officer (RHD)Radiation Board Licensing Office 3/F Sai Wan Ho Health Centre, 28 Tai Hong Street, Hong Kong Fax: 2834 1224 e-mail Address: enquiry@erls.gov.hk

RADIATION ORDINANCE

(Chapter 303)

APPLICATION FOR IRRADIATING APPARATUS LICENCE

I (Name of full)

of (Address in full)

hereby make application for a licence (a)

irradiating apparatus as described hereunder, at (b)

2. Description of type or types of irradiating apparatus for which licence is required :

3. My qualifications are as follows (c)

Date this day of 20

Signature of Applicant.

(a) State purpose for which licence is required, i.e. to possess, sell, manufacture, operate, etc. (b) State address at which such irradiating apparatus will be situated. (c) This paragraph need only be completed in the case of an application to operate irradiating apparatus.

DH1271(s)

輻 射 條 例 (第 303 章 ) RADIATION ORDINANCE (CAP 303)

新申領管有一具處於可運作狀態的輻照儀器的牌照 First Application for a Licence to Possess

an Irradiating Apparatus in a Functional State

請參閱夾附的「申請須知」後，填寫本表格適用部分。 Please refer to the attached "Notes for Applicants" and complete the appropriate sections.

請在適當地方加上 Please tick as appropriate

A. 申請人資料 Particulars of the applicant

以個人名義申請牌照，請填寫 A1段；以公司名義申請牌照，請填寫 A2段。Licence in the name of a person, please complete Section A1; Licence in the name of a company, pleasecomplete Section A2.

.

稱謂 Tit le

A1 醫生 Dr 博士 D r 先生 Mr 女士 Mrs 女士 Ms 小姐 Miss

姓名 Name

姓 (Surname) 名(Given name)

身分證/證明文件編號. Identity Card/Document No.

電郵 E-Mail

或 or A2

公司名稱 Name of company

商業登記編號

稱謂 Tit le

Business Registration No.

醫生 Dr 博士 D r 先生 Mr .女士 Mrs 女士 Ms 小姐 Miss

與此申請有關的獲授權人士姓名 Name of authorized person in relation to this application

姓(Surname) 名(Given name)

身分證 /證明文件編號 . Identity Card/Document No.

電郵 E-Mail

通訊地址 Correspondence address :

稱謂 Tit le 醫生 Dr 博士 D r 先生 Mr .

女士 Mrs 女士 Ms 小姐 Miss

聯絡人姓名 Name of Contact Person : 姓 (Surname) 名(Given name)

電話號碼 Tel No. : 手機號碼 Mobile No.:

傳真號碼 Fax No. : 電郵 E-Mail:

只供輻射管理局填寫 FOR OFFICIAL USE ONLY 收件日期 Date received

費用 Fee A B C D E F

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B. 輻照儀器資料 Details of the irradiating apparatus

製造商 Manufacturer

型號 Model No.

控制臺/機身編號 Control Panel/

Machine Serial No.

X射線球管編號 X-ray Tube Head

Serial No.

此輻照儀器原記錄於 This irradiating apparatus is presently covered by 輻照儀器牌照編號

Irradiating Apparatus 有效期至 / /Licence No. Valid until

日 D 月 M 年 Y 現申請管有該輻照儀器，以便 I hereby apply to possess the irradiating apparatus

從準備狀態轉為可運作狀態。 From preparatory state to functional state.

從原址作內部遷置。 After a relocation within the original premises.

從貯存狀態轉為可運作狀態。 From storage state to functional state.

從原有持牌人接管該儀器 (請夾附轉讓表格 IA-TRAN)，本人確定該裝置場址的原有布置，包括輻照儀器位置和所有防護物料都維持不變。 Upon a transfer of the irradiating apparatus from the present licensee (please attach Transfer Form IA-TRAN). I hereby confirm that there has been no change in the premises, including the material protection and location of the irradiating apparatus.

C. 固定輻照儀器的輻射防護 Radiation shielding of static irradiating apparatus

(i)

或 or (ii)

輻照儀器乃置於防護罩內。防護罩屬儀器的組件。在正常操作情況下，距儀器表面 5 厘米任何一點的罩外輻射水平不超過每小時 5微希沃特。 The irradiating apparatus is contained in a shielded enclosure which forms an integral part of the apparatus and under normal operating condition the radiation level outside the shielded enclosure does not exceed 5 microsievert per hour at a distance of 5 cm from any readily accessible point on the surface of the apparatus.

請到 F部繼續填寫 Please continue from Section F

防護資料 Shielding is available as follows :

防護質料 shielding material 厚度(毫米) thickness (mm)

地板

天花

牆壁

門

Floor

Ceiling

Walls

Doors

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D. 裝置場址內備有的個人保護物品 Personal protective measures available in the premises

鉛膠保護衣 Lead rubber apron

性腺屏蔽 Gonad shield

個人輻射劑量計 Personal radiation dosimeters

E. 使用該輻照儀器人士 (如下列空間不足填寫，請附夾資料 )Person(s) using the irradiating apparatus (please attach separate sheets if the space below isinsufficient)

姓名 身分證編號 《使用輻照儀器》牌照編號 Name Identity Card No. “USE” licence No.

本人不擬准許上述領有牌照的人士使用造影劑以拍攝人體醫學照片。 I do not intend to allow the above licensed person(s) to administer contrast media for taking of medical exposure of human bodies.

本人擬准許上述領有牌照的人士使用造影劑以拍攝人體醫學照片及已在樓宇內備妥適當的急救

藥物及復甦設備。 I intend to allow the above licensed person(s) to administer contrast media for taking of medical exposure of human bodies and have made available the appropriate life saving drugs and resuscitation equipment in the premises.

F. 聲明 Declaration

本人明白上列於 E 部的使用輻照儀器人士須持有有效之《使用輻照儀器》牌照或在一位持有有效《使用輻照儀器》牌照之註冊醫生、牙醫或放射技師親自督導下，方可按法例 303B章第 26節規範下操作該輻照儀器。現聲明盡本人所知，本申請所載資料均真確無誤。

I understand that the person using the irradiating apparatus as listed in Section E shall be a person who isholding a valid licence to use the concerned type of irradiating apparatus or is acting under the personalsupervision of a doctor or dentist or radiographer who is holding a valid licence to use the concerned typeof irradiating apparatus in accordance with Regulation 26 of Cap.303B for such purposes. I declare thatto the best of my knowledge the information in this application is true and accurate.

申請人/獲授權人簽名 授權 Authorization Signature of Applicant/Authorized Person 公司印鑑 (如適用) Company chop (if applicable)

姓名（請用正楷書寫） Name (in block letters) 日期 Date

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輻 射 條 例 (第 303 章 ) RADIATION ORDINANCE (CAP 303)

新申領管有一具處於可運作狀態的輻照儀器的牌照 First Application for a Licence to Possess

an Irradiating Apparatus in a Functional State

申 請 須 知 Notes for Applicants

1. 申請 Application

請注意，每具輻照儀器均須個別領有牌照。 Please note that each irradiating apparatus shall be covered by a separate licence.申請人可填寫表格 DH1271(S) 和 IA-P2申請持有輻照儀器。You should complete Form DH1271(S) and IA-P2 form for each irradiating apparatus.

2. 輻照防護物料 Material protection of radiation

根據輻射 (管制輻照儀器 )規例第 17條第(1)款規定，在連續使用輻照儀器房間外的輻射劑量率，不得超過每小時 3微戈瑞。Regulation 17(1) of the Radiation (Control of Irradiating Apparatus) Regulations requires that the radiation dose rate outside theroom where the irradiating apparatus is to be used continuously shall not exceed 3 micrograys per hour.

3. 遞交申請書 Submission of application

填寫的申請表格須送回 : This application should be submitted to:

香港西灣河太康街 28號西灣河健康中心 3字樓 電話 : 2886 1551 輻射管理局牌照事務處 傳真 : 2834 1224

電郵 : ia@erls.gov.hk

網域 : http://www.erls.gov.hk

Rad ia t ion Board L icens ing Of f i ce Tel. : 2886 1551 3/F., Sai Wan Ho Health Centre Fax : 2834 1224 28 Tai Hong Street, Sai Wan Ho, Hong Kong E-mail : ia@erls.gov.hk

Domain : http://www.erls.gov.hk

申請費用為 $1,150。當輻射管理局收到有關申請後，會向申請人發出一般繳款單，申請人請依照一般繳款單內所列的繳款辦法繳付所需費用。

假如申請最終被否決，已繳交的款項將盡快全數退還。 The app l i ca t ion fee i s $1 ,150 . A f te r rece iv ing the app l i ca t ion , the Rad ia t ion Board w i l l i ssue a Genera l Demand Note to the app l i can t . The app l i can t cou ld make payment accord ing to the payment i ns t ruc t i ons s ta ted in the Genera l Demand No te . Shou ld the app l i ca t ion be unsuccess fu l , t he pa id amoun t w i l l be re funded to the app l i can t as soon as poss ib le .

4. 按情況需要連同申請書一併遞交的文件 Documents to be submitted with the application (if applicable)(i) 輻射管理局允許申請人持有擬安裝及使輻照儀器處於可運作狀態之輻照儀器牌照正本。

The original copy of the licence permitting you to possess the irradiating apparatus, for installation and testing purposes orotherwise, while your application for possessing the apparatus in a functional state is being considered by the RadiationBoard.

(ii) A1段 - 申請人的身分證 /證明文件副本和 45x60(毫米)近照兩張。Section A1 - Copy of Identity Card/Document of the applicant and 2 recent photographs of size 45 x 60(mm).

A2段 - 商業登記證和獲授權人士身分證 /證明文件的副本。Section A2 - Copy of the Business Registration Certificate and Copy of Identity Card/Document of the authorized

person. (iii) B部 - 輻照儀器的技術規格

Under Section B - Technical specifications of the irradiating apparatus(iv) C(ii) 部 - 顯示防護物料、輻照儀器位置，主輻射束方向及毗鄰地方用途的樓面布置圖。

Under Section C (ii) - A floor plan of the premises showing the material protection, location of the irradiating apparatus, directions of the primary radiation beams and utilization of the adjacent areas.

(v) 輻照儀器擁有權的證明文件 (例如：發票副本、轉讓輻照儀器的證明書 )Documentary evidence to show the ownership of the irradiating apparatus (e.g. invoice copy, proof of transfer of irradiatingapparatus)

(vi) 選擇表格 (如適用 ) Option form (if applicable) 注意 Remarks : (i) 在使用可產生輻射影響人體的輻照儀器前，申請人須確保使用者必須持有有效的《使用輻照儀器》牌照，或使用者必須在一位持有有效《使用輻照儀器》牌照之註冊醫生、牙醫或放射技師在治療 /檢查現場親自督導下，方可進行。 Before the use of the irradiating apparatus to produce radiation affecting human body, you should ensure that users of thisirradiating apparatus should hold a valid ‘use’ licence or the users are working under the personal supervision of a registered doctoror dentist or radiographer holding valid “use” licence who must be present on the premises in which the treatment/examination istaking place at the time it takes place.

(ii) 表格中所列的所有有關牌照必須於呈交本申請書時仍為有效。有關牌照持有人請於牌照屆滿前八個星期把填妥之申請書及所需文件交到輻射管理局。否則，本局有可能在牌照屆滿前未能完成處理有關牌照的續牌申請。逾期管有輻照儀器乃違反輻射條例第 7(1)條的罪行，一經定罪，可判處罰款 $50,000及監禁 2年。 Any current licence mentioned in this application must remain valid on the date of submission of this application. The Licenseeshall submit the duly completed application form together with the required documents to the Radiation Board 8 weeks beforeexpiry of the licence. Otherwise, the Board may not be able to complete processing of the licence renewal application before itsexpiry. Possessing an irradiating apparatus without a valid licence is an offence to section 7(1) of the Radiation Ordinance, andshall be liable to a fine of $50,000 and to imprisonment for 2 years.

表格IA-P2 (2018 年9 月生效) FORM IA-P2 (Effective September 2018) 輻 射 管 理 局

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http://www.erls.gov.hkhttp://www.erls.gov.hk

Collection of Personal Data ver.9_2012DH1271e_fillableIA-P2_fillable

DH1271e_1: DH1271e_2: DH1271e_3: DH1271e_4: DH1271e_5: DH1271e_6: DH1271e_7: DH1271e_8: DH1271e_9: DH1271e_10: DH1271e_11: DH1271e_12: DH1271e_13: IA-P2_2: OffIA-P2_3: IA-P2_3a: IA-P2_4: IA-P2_5: IA-P2_6: IA-P2_7: IA-P2_8: OffIA-P2_9: IA-P2_9a: IA-P2_10: IA-P2_11: IA-P2_12: IA-P2_13: IA-P2_14: OffIA-P2_15: IA-P2_15a: IA-P2_16: IA-P2_17: IA-P2_18: IA-P2_19: IA-P2_20: IA-P2_21: IA-P2_22: IA-P2_23: IA-P2_24: IA-P2_25: IA-P2_26: IA-P2_27: IA-P2_28: OffIA-P2_29: OffIA-P2_30: IA-P2_31: IA-P2_32: OffIA-P2_33: OffIA-P2_34: OffIA-P2_35: IA-P2_36: IA-P2_37: IA-P2_38: OffIA-P2_39: IA-P2_40: